The URL can be used to link to this page

36 OCEAN AVE - BUILDING INSPECTION (2) / The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only $uilding Per mber A Date A 'At d: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Ad/dr�es_s:/ ,J 1.2 Assessors.Map&Parcel Numbers E�(O X(tt—it v /--I�II� L l a Is this an accepted street?yes_\,� no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if yesO Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: C➢S�.r1�2 rn��1C = sS'4�jT fY1 r?A o�q?o Name(Print) City,LS/t'/ate,ZIP nand Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify.- Brief Description of Proposed Work- SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials) Official Use Only 1.Building $ r(o 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: - 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 2/ 0 ❑Paid in Full ❑Outstanding Balance Due: �'�y of 49 Name owe SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) z d'z�•zoo 3 License Number Expiration Date Name of CSL Holder P V/ � n-1` I 1 ��L rn�� List CSL Type(see below)_ No.and Street �1 Cz'"m Type Description U Unrestricted(Building,up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling 'City/Town,State,ZIP M Masonry RC Routing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Tel hone �° Email address D Demolition Registered Home Improvement Contractor(HIC) y HIC Registration Number Expiration Dale Cotpl any Nam nor HIC R gas ame fl d tree[ M}' 2 n&!' 9�/ Email address City/Town,State,ZIP < Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ........ . No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize* T�`j> Ju to act on my behalf,in all matters relative t work author' ed/d by this building permit a placation. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information co fined in this application is true and orate to the be,t of t y knowledge and understanding. ao/z riot Owner's or Authorized Agent's N ne(Electronic gnature) Date NOT 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass. ovg /dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" . ° CITY OF S��I.E�M UI sS.kcHuSETTS ButLDL\G DEPARTMENT \ 8� 130 WASHNGTON STREET, 3BO FLOOR TEL (978) 745-9595 F.ALx(979) 740-9846 KINIBE i.-EY DRISCOLL MAYOR T Ho\w ST.PmRRE DIRECTOR OF PIBLic PROPERTY/BUUMLNG CONMSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11, S 150A. The debris wi li be transported by: j-- (name of hauler) The debris will be disposed of in (name of facility) (address of facility} sienature of permit appkicant state Jdrri eail.d<n; aCITY OF S.U.FNI NLkSSACHLSETTS BULDIING DEPiMIL-4T I—V W.�tLNGTON STREET,Via FLOOR TEL (978)745-9595 FAX(978)740-9M KI\IBE.RLJ2.Y DRISCOLL MAYOR Ti O&W STTUERRE DIRECTOR OF Punic PROPERTY/BL'ILDLNG CONMUSSIONEA Workers'Compensation Insurance Affidavit:Builders(Contractors/EleMricians/Ptumbers Applicant Information Please Print Legibly ?lama (,Bus arss OrganizatioMndividual):�nn�C1 j t+�} \j SOQ�&_ySFQyC\rC(r <<��! Address:_ City/State/Zip: Phone �16J'' r o w Are you as emptoyer?Cheek the appropriate hoa: project Type of P J (required): 1.Q I am a employer with 4. ❑ I am a general contractor and I 6. Q New construction Aployea(full and/or part-title).` have hired the sub-contractors, 2N I am a sole proprietor or pauper- listed on the attached sheet.: 7. Q Remodeling ship and have on employees These sub-contractors have S. Q Demolition working.for me in any capacity, workers'comp.insurance. 9. Q Building addition [NG.workets comp.insurance 5. ❑ We are a.corporation and its required.] officers have exercised their 10.©Electrical repairs or additions 3.® 1 am a homeowner doing all work right of exemption per MGL 1 LO Plumbing repairs or additions myselE.[Na,workers'comp. c. 152,§I(4),and we have no 12.Q Roof repairs insurance required.)t employees.(No workers' 13.❑Ofher. comp.insurance required.) 'Any applicant that ducks box 91 most al,,- fill out the section below showing their wortni compensation p uey intormation.. 'Il meowtcas who submit atis affidavit indicating they ate daring all sort and the hire mttside"to um.meet submit a new affidavit indcating sacd 4:ammeoan that sheet this boas must attached an edditaxof duet showing arc name of the ub ccm,,tars atut their wodten'comp,policy in(onnodm lam as employer thatts providing workers'eumpensadon imoraneefor my eurplayees Belaw Ir thepollcy andjob site irtformatiam Insurance Company Vame: Policy S or Scif-ins.Lic.H: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'eompeasation policy deelaratloa page(showing the policy number and expiration date). Faifure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine . of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DFA Far insurance coverage verification 7f,"'Ite re terrify n pains and I ties of perjury that the information provided abovvee is true and correct re Date �d" Z Ojjtial use wily. Do not write in thin area,lobe cuorpleted by city or(alum xiuL City or Town- Permit/I.icense# issuing Authority(circle one):. 1. Board of health L Building Department 3.CityfFawn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Oliver Contact Person: Phone#: